Payer / Provider Interoperability

Prior authorization and utilization reviews are fading, and in their place will be more collaborative models based on real‐time eligibility, benefit verification, Rx interactions, access, quality, safety, effectiveness and patient centeredness. Provider education and engagement and primary care integration/coordination will require more health plan resources and attention. Bundled payments, P4P and other initiatives holding providers accountable for cost and quality, as stressed by ACO’s, PCMH’s, Bridges To Excellence (BTE), Leapfrog and other initiatives, will continue to expand.